Outcomes following liver transplantation in intensive care unit patients

AIM:To determine feasibility of liver transplantation in patients from the intensive care unit (ICU) by estimating graft and patient survival.METHODS:This single center retrospective study included 39 patients who had their first liver transplant directly from the intensive care unit and 927 non-ICU patients who were transplanted from hospital ward or home between January 2005 and December 2010.RESULTS:In comparison to non-ICU patients,ICU patients had a higher model for end-stage liver disease (MELD) at transplant (median:37 vs 20,P < 0.001).Fourteen out of 39 patients (36%) required vasopressor support immediately prior to liver transplantation (LT) with 6 patients (15%) requiring both vasopressin and norepinephrine.Sixteen ICU patients (41%) were ventilator dependent immediately prior to LT with 9 patients undergoing percutaneous tracheostomy prior to transplantation.Twenty-five ICU patients (64%) required dialysis preoperatively.At 1,3 and 5 years after LT,graft survival was 76%,68% and 62% in ICU patients vs 90%,81% and 75% in non-ICU patients.Patient survival at 1,3 and 5 years after LT was 78%,70% and 65% in ICU patients vs 94%,85% and 79% in non-ICU patients.When formally comparing graft survival and patient survival between ICU and nonICU patients using Cox proportional hazards regression models,both graft survival [relative risk (RR):1.94,95%CI:1.09-3.48,P=0.026] and patient survival (RR:2.32,95%CI:1.26-4.27,P=0.007) were lower in ICU patients vs non-ICU patients in single variable analysis.These findings were consistent in multivariable analysis.Although not statistically significant,graft survival was worse in both patients with cryptogenic cirrhosis (RR:3.29,P=0.056) and patients who received donor after cardiac death (DCD) grafts (RR:3.38,P=0.060).These findings reached statistical significance when considering patient survival,which was worse for patients with cryptogenic cirrhosis (RR:3.97,P=0.031) and patients who were transplanted with DCD livers (RR:4.19,P=0.033).Graft survival and patient survival were not significantly worse for patients on mechanical ventilation (RR:0.91,P=0.88 in graft loss;RR:0.69,P=0.56 in death) or patients on vasopressors (RR:1.06,P=0.93 in graft loss;RR:1.24,P=0.74 in death) immediately prior to LT.Trends toward lower graft survival and patient survival were observed for patients on dialysis immediately before LT,however these findings did not approach statistical significance (RR:1.70,P=0.43 in graft loss;RR:1.46,P=0.58 in death).CONCLUSION:Although ICU patients when compared to non-ICU patients have lower survivals,outcomes are still acceptable.Pre-transplant ventilation,hemodialysis,and vasopressors were not associated with adverse outcomes.

Intraoperative intracardiac thrombosis in a liver transplant patient

A 66-year-old female with cryptogenic cirrhosis complicated by ascites,hepatic encephalopathy,variceal bleeding and malnutrition with MELD of 34 underwent orthotopic deceased donor liver transplantation performed with piggyback technique.Extensive eversion thromboendovenectomy was performed for a portal vein thrombus which resulted in an excellent portal vein flow.The liver graft was recirculated without any hemodynamic instability.Subsequently,the patient became hypotensive progressing to asystole.She was resuscitated and a transesophageal probe was inserted which revealed a mobile right atrial thrombus and an underfilled poorly contractile right ventricle.The patient was noted to be coagulopathic at the time.She became progressively more stable with a TEE showing complete resolution of the intracardiac thrombus.